What is the procedure for diagnosing and treating hyperaldosteronism (high aldosterone levels)?

From the Guidelines

Diagnosing and treating hyperaldosteronism involves a systematic approach beginning with screening tests followed by confirmatory testing and appropriate treatment, with the most recent guidelines recommending medical management with mineralocorticoid receptor antagonists for bilateral disease and laparoscopic adrenalectomy for unilateral disease 1. The initial step in diagnosing hyperaldosteronism is to measure the aldosterone-to-renin ratio (ARR) in patients with hypertension, unexplained hypokalemia, or adrenal incidentalomas.

• Key points to consider in the diagnosis include:
  • Elevated plasma levels of aldosterone and low levels of renin activity, with a plasma aldosterone-to-renin ratio usually greater than 30 1.
  • Confirmatory testing with the saline suppression test or salt loading test may be indicated to rule out false-positives and false-negatives.
  • Electrolytes should also be measured, as excessive aldosterone production causes retention of sodium and excretion of potassium. Once hyperaldosteronism is confirmed, imaging studies like CT or MRI of the adrenal glands help determine if the condition is unilateral (typically an aldosterone-producing adenoma) or bilateral (idiopathic hyperaldosteronism).
• For unilateral disease, laparoscopic adrenalectomy is the preferred treatment, often resulting in cure or significant improvement of hypertension and normalization of potassium levels 1.
• For bilateral disease, medical management with mineralocorticoid receptor antagonists is recommended, typically starting with spironolactone at 50–100 mg once daily, which can be titrated up to 300–400 mg once daily, if necessary 1. Patients should be monitored for side effects such as hyperkalemia, especially when combined with other potassium-sparing medications or in patients with renal impairment.
• Regular follow-up to assess blood pressure, electrolytes, and renal function is essential for optimal management of this condition. It is also important to note that newer agents, such as the non-steroidal MRAs finerenone and exarenone, and the aldosterone synthase inhibitor baxdrostat, are being tested for treating primary aldosteronism, but their use is not yet widely established 1.

From the FDA Drug Label

2.5 Treatment of Primary Hyperaldosteronism Administer spironolactone tablets in doses of 100 mg to 400 mg daily in preparation for surgery. For patients who are considered unsuitable for surgery, spironolactone tablets can be used as long-term maintenance therapy at the lowest effective dosage determined for the individual patient. 1.4 Primary Hyperaldosteronism Spironolactone tablets are indicated in the following settings: Short-term preoperative treatment of patients with primary hyperaldosteronism. Long-term maintenance therapy for patients with discrete aldosterone-producing adrenal adenomas who are not candidates for surgery Long-term maintenance therapy for patients with bilateral micro or macronodular adrenal hyperplasia (idiopathic hyperaldosteronism).

The procedure for diagnosing hyperaldosteronism typically involves a blood test to measure aldosterone levels. The treatment for hyperaldosteronism with spironolactone involves administering the drug in doses of 100 mg to 400 mg daily in preparation for surgery, or as long-term maintenance therapy at the lowest effective dosage determined for the individual patient 2 2. Key considerations for treatment include:

• Dosage: 100 mg to 400 mg daily
• Administration: in preparation for surgery or as long-term maintenance therapy
• Patient selection: patients with primary hyperaldosteronism, including those with discrete aldosterone-producing adrenal adenomas or bilateral micro or macronodular adrenal hyperplasia.

From the Research

Diagnosis of Hyperaldosteronism

• The diagnosis of hyperaldosteronism typically involves a blood test to measure the levels of aldosterone and renin in the body 3.
• The aldosterone to renin ratio (ARR) is a key step for early detection of primary aldosteronism, and an Application has been developed to provide a swift calculation of the ARR regardless of the units of measure used for plasma aldosterone and renin values 3.
• In some cases, patients with primary hyperaldosteronism may have normal to high normal PRA levels, which can make diagnosis more challenging 4.

Treatment of Hyperaldosteronism

• The treatment of primary hyperaldosteronism depends on the underlying cause, with aldosterone-producing adenoma and unilateral adrenal hyperplasia being amenable to cure by endoscopic adrenalectomy 5.
• Bilateral adrenal hyperplasia is typically treated with mineralocorticoid receptor antagonists, such as spironolactone, starting at a dose of 12.5-25mg/day and titrating up to 100mg/day as needed 5.
• Alternative treatments, such as a triamterene-thiazide combination, may be effective in some patients with primary aldosteronism who do not tolerate spironolactone 6.
• In patients with low-renin hypertension and elevated aldosterone-renin ratio, a thiazide diuretic, such as bendroflumethiazide, may be as effective as spironolactone in lowering blood pressure 7.

Management of Hyperaldosteronism

• Patients with primary hyperaldosteronism require close monitoring of serum electrolyte and creatinine levels, particularly when starting medication 5.
• Spironolactone therapy may cause an increase in serum creatinine and potassium levels, and patients should be closely monitored for these effects 4.
• Early specific treatment of primary hyperaldosteronism is indicated, and even patients with advanced hypertension may benefit from adrenalectomy or cautious spironolactone treatment 4.